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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)458-3420 <br /> NON-REFUND <br /> ABLE <br /> PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROMDATE ISSUED <br /> JOB ADMEN '( aS`IF- (AUT6 <br /> 11N OYt / 533- <br /> CROSS STREET APN 2S1-2V6-L19 ���1 <br /> ,/ _PARCEL SQE.f. T�'•"4.ANU USE APPLICATION <br /> DWNER NAME 5QI91"t y VAft P A I -IVt PHONE (?52—/39 61 y <br /> OWNER ADDRESS _ISS—I_�Yf.vL1N S6� RJ ___ CITYISTATE21P MA A'�� L— q 3 / _ <br /> CONTRACTOR Mctssf-1 f1 S DI-1111"f Z)r(- PHONE 52-2- 1.17 5 <br /> CONTRACTOR ADDRESS Ilq &16.3 i124 CITYISTATEZPI aj P,I}d/ C< <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADMEN CRY/STATEZP <br /> LICENSE >KC-57 C-61 D-09 ;:100gr NW19ERhGu6Z7. EXPIRATKm DATE <br /> GEOGRAPHICALINIbR1AATION: COOrdlnet"X Y Township_ Range_ Section_ <br /> INTENDED USE 1 DOmestic/Pnvat6 IrrigallorVAgricultural ! Industrial IWater Quality Monitoring SOA Sampling/Chamcteization <br /> I Public Water System <br /> Il daereM kom Oaner: ner y—e vdad rre or u r <br /> TYPEOFWORK XNew Well Replacement Well Well Alleration/Modficallon :Other <br /> Monitoring Wallis) #of wells Soil Bodngis) rot b'""as i'Geolechnical ro10oro' <br /> Out-Of-Service Well Out-Of-Service Well Renewal i Cross-Connection Repair <br /> New Pump Pump Replacement I Pump Repair Raise Well Casing <br /> WELL CONSTRICT <br /> Drilling Method>eMud Rotary i Air Rotary Auger I Cable Tool Push Point i Other <br /> Proposed Well Depth <br /> N Excavation 74;j'_In diameter -Open Bosom )(Gravel Pack/Gravel Siz in diameter <br /> Conductor Casing In diameter / CorMuctm Casbg Depth h <br /> Well Casing Diameter U2 In Thickness/Gauge/ASTM Schad 6?Sp y Steel �.AP.la�stic - Stainless Steel ,Other <br /> Grain Seal Depth 50 h Neel Cement(941b boo-10 gel water) J nd Cement/O. { sack m/d7 gal water <br /> 1 Bentonite(20%solids) Other <br /> Grout Placement Method mped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contracts Other <br /> Conuete Pedeatel Dimensions:Width_ft Ler filth K Thick In -Christy Box Stove Pipe <br /> PUMP SubmemiWal'Turbine Other HP PUmPSet K Standing Water Level R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT i AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MI UMa2�4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953.76977 <br /> SIGNED �OL/l_ TITLE [-) t II P✓ DATE 5 �-/Q <br /> 4' <br /> l <br /> LClil <br /> , <br /> A T N <br /> �AtNSb'E S TMENT USE ONLY MEW Accepted By la S D b Area /9 R Employee IDA ( !�OLult <br /> Grout Inspection By Dete r;2 SPECIAL Well Permit <br /> Pump Inspection By / Dale_ �.I WAIVER Received <br /> Soil Boring Insp'cibn Sy _Date Constructed Well Depth N <br /> COMMENTS <br /> PE SC Received Amount Dab panni/ Invoice# WSII ID# <br /> Coffee Info By Remitted Sarvke Request# <br /> 4369 ISD �/ 3 t6 3rFf-T-d S-It7-16 5 ' 7 � 7. <br />